Can Health Care Treat Crime?

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Early one morning in March, Donald Williams climbed into a twelve-seat van and headed toward San Quentin State Prison. As he drove, he swilled coffee while the rising sun turned the sky a hopeful pink. At the prison gates, he was greeted by guards who remember when he was a drug-addicted recidivist who cycled in and out of prison. The prison vehicle carrying soon-to-be released inmates stopped just outside the gate and Williams gave the guard the name of his pickup. The guard called out: "Copeland!"

From the rear of the vehicle emerged a skinny 36-year-old with short-cropped hair and a cane.Charles Copeland wore a gray sweatshirt, gray sweatpants, and white tennis shoes that he bought for three books of stamps, the currency of prison. In his arms, he cradled a paper sack filled with medications and inhalers for his numerous ailments: lupus, asthma, depression, and a congenital heart problem that sometimes gives him chest pains.

Williams ushered Copeland into the back of the van, and they made small talk as they drove back to Oakland. Copeland, whose original incarceration was for selling heroin, told Williams he'd been imprisoned for three months because he didn't report to his parole officer the last time he got out. Williams spoke with familiarity about prison and parole, and feeling more at ease with Williams, Copeland asked to borrow a cell phone to call his grandmother. Williams obliged, and the elderly woman's surprise, worry, and frustration were audible from the headset.

Once back in Oakland, Williams deviated from his usual routine by pulling through a McDonald's drive-through to buy some breakfast for Copeland since inmates are released without a meal. The parolee took careful but appreciative bites of an Egg McMuffin, as Williams rolled on to the morning's next stop: Healthy Oakland, a community medical clinic that works with ex-offenders such as Copeland.

But Williams wasn't just offering Copeland a ride and a meal. This warm handoff from San Quentin to Healthy Oakland is part of a growing national effort to connect people released from jails and prisons to health care soon after release.

Healthy Oakland, which received its state medical clinic license last year, takes a public-health approach to public safety. This past fiscal year, the clinic received $1.2 million from the county to serve as a one-stop health and social services center for the poor. In addition to its clinic, the "Save a Life Wellness Center," visitors can get help signing up for housing, employment, food stamps, even tax preparation.

"If our charge is to make communities healthier, then we have to look at all of the indicators that are causing a community to be unhealthy," says Anita Siegel, acting director of the Alameda County Public Health Department. "And we know violence is one of them. And we also know that the reentry population is coming to Oakland. And if there are no jobs or resources available, then they could end up committing crimes — which will continue the cycle of producing communities that aren't healthy."

Health care and violence prevention may not seem related, but Alameda County is betting there's an important connection between the two. For the past half-decade, the county's Public Health Department has been active in a growing movement that addresses social issues such as poverty, education, and crime as a way of creating healthier communities.

The many connections between social issues and public health are clear, but the reasons for them — what exactly causes what and how — remain unclear. But for now, the Public Health Department and clinics such as Healthy Oakland aren't fixating on the why. They believe that providing a combination of social and health services is one way to chip away at core problems like violence and crime.

Community Oriented Correction Health Services, a nonprofit organization based in Oakland, is at the forefront of this effort. It has helped create programs across the country that bridge medical care between jails and the communities where ex-offenders return. "Given the economic climate and the growth in incarceration, we are rethinking public policy on public safety," noted program medical director Dr. Keith Barton, who also has practiced at Santa Rita Jail. "There are multiple interventions for ex-offenders and health care is one of them, with substance abuse treatment being an important subset of that."

Since many offenders have substance-abuse or mental-health problems connected to the crimes they've committed, corrections departments and criminal justice policymakers argue that investing in medical care during reentry is good for public safety. "A lot of offenders come back to the system because, although they were stabilized while incarcerated, when they leave, they decompensate once they go off their medication and they go back to the behavior that got them arrested in the first place," observed Captain Ron McCuan, a health analyst with the National Institute of Corrections. "That's why corrections is taking such a long look at the continuity of care, and connecting with public health."

Meanwhile, elected officials note that attending to parolee health makes obvious financial sense because it's more cost-effective to treat ex-offenders — who tend to be less healthy and have higher rates of infectious disease than the general public — before they wind up in the emergency room.

Still other proponents see health care services as a "carrot to bring people in to talk about their other issues that are germane to reentry," said Sherri Willis, Alameda County Public Health's public information officer. "It's a medical model, using health as a portal to reach people to give them other types of services."

For some, the ultimate hope is that in reaching parolees through their health care needs, such ex-offenders can then be connected to other services that will steer them away from returning to prison. Some studies even suggest that connecting parolees with health produces lower rates of recidivism, although the evidence of this remains weak.

Whatever the motivation, parolees like Charles Copeland are benefitting from the growing effort to deliver ex-offenders to the doctor's office right out of the prison gates.

Alameda County began looking seriously at violence as a public health question under the tenure of Arnold Perkins, director of the Public Health Department from 1994 to 2006. "The murders in Oakland are part of an infectious disease," Perkins said recently. "I rape you, your brother kills me, my son kills your brother, and then your brother's friend kills my son and it goes on and on. It's contagious. If we had an outbreak of spinal meningitis, we would be on it. We have maybe two deaths per year from spinal meningitis, and we had 125 deaths by murder last year, and most of the people knew each other and they have common characteristics — they had not finished high school, most of them had an unstable family situation. So to me, they are not in a wellness environment. They are in an environment of disease."

And although health department officials say they've always seen violence-prevention as a part of their mandate, the county formalized its efforts in 2005 when the Oakland-based Prevention Institute, a Centers for Disease Control-funded organization, helped bring local agencies together to create a violence-prevention blueprint. This was a definitive effort to look at the myriad underlying social issues that led to crime and violence, a realization that neither putting more police on the beat nor opening more community clinics for the poor was going to singlehandedly fix the problem.

"In Oakland and Alameda County, there has been a deliberative strategy where public health and public safety have worked together," Prevention Institute Executive Director Larry Cohen said. "That strategy addresses underlying issues like jobs, education, and intermediary issues like mentoring, tutoring, and crime interruption programs. Ideally, we would get to people before they go to prison. We don't want prison to be an acceptable part of community life. We do not want neighborhoods where there are few boys and men because so many are in prison."

In 2007, Perkins also founded the Alameda County Reentry Networkto bring together law enforcement, corrections, and social services to coordinate services for ex-offenders.

Healthy Oakland is an organization that's attempting to treat crime and violence in a more systemic way by using health as a gateway. Founded by African-American church and medical leaders, the organization adopted a mission of helping the most difficult to help, including parolees such as Charles Copeland.

"We wanted to work with men and women coming out of prison, and if they were serious, then we wanted to provide them services so they couldn't say, 'Well, I got this problem and that problem,'" said Pastor Raymond Lankford, one of the clinic founders. "That was the purpose — to provide the type of support that men or women needed so could get to the next level. There are some who are struggling and who are not sure because they've never had a real support system outside of a family that was broken down, so it is difficult. But we believe in reaching as many as we can."

Housed in a fading rose-colored building on the corner of 26th Street and San Pablo Avenue, Healthy Oakland is located in what could be called ground zero for social and health disparities in Oakland. The county Public Health Department found that there's a ten-year difference in life expectancy between residents of East and West Oakland and those who live in the Oakland Hills. East and West Oakland, where more than 30 percent of the families live in poverty, suffer from higher rates of death and illness from violence, injury, chronic diseases, and communicable diseases. These are also the neighborhoods where the most parolees return after being released from prison. Thus, Healthy Oakland's location was no accident. "We feel it's important to be in the community where the stakes are highest," said Dr.Geoffrey Watson, Healthy Oakland's medical director.

The interconnection of these health and socio-economic challenges are not difficult to comprehend and perhaps not even surprising. But maps created by the Public Health Department show that violence, poverty, chronic illness, and high rates of mortality are clustered in specific neighborhoods. As the statistics have borne out, in Oakland, it's primarily East and West Oakland that assume the greatest burden of harm.

"If you look at premature deaths or chronic diseases and you map it out, there are certain neighborhoods where that is occurring," said Siegel of the Public Health Department. "If you overlay those maps with people who are on parole and where violent crimes happen, it's all of the same areas."

For Pastor Lankford, the connection between health and violence is not theoretical. He lost a half sister, an aunt, and two teenaged nephews to gun violence. The health clinic has a space dubbed the Hall of Peace, a memorial wall of photos of people who had been caught in the gunfire. "This is how we started, because of the escalated violence in 2001," Lankford said. "We keep this information posted because we want people to realize the harmful impact and effects of violence perpetrated against others."

Dr. Watson, the clinic's medical director, underscored this point a few weeks later when he pulled from his bookshelf a volume titled "Violence in Oakland: A Public Health Crisis" that revealed that 77 percent of homicide victims in Alameda County are African American. "Health is a state of spiritual and socio-economic and psychological and physical well-being and not simply the absent of disease," he said.

Healthy Oakland and Alameda County are not alone in their view. "The reality is that health care only accounts for 15 percent of a populations' health," explained Brian D. Smedley, vice president and director of theHealth Policy Institute of the Joint Center for Political and Economic Studies in Washington, DC. "What is important for health is not your genetic code, but your Zip code, and the next wave of public health is to address people outside of health care and look at the neighborhood and community factors."

When Charles Copeland arrived at Healthy Oakland on the morning of his release, there was already a line of people waiting for the clinic to open its doors so that they could be seen for issues ranging from the flu to managing chronic illnesses such as diabetes or hypertension.

Copeland was handed a stack of forms and a pen to help the clinic figure out what kinds of services he needed. Address? Homeless. Referred by? San Quentin. Are you on probation or parole? Yes.

He sat with an intake officer who signed him up for temporary county indigent medical coverage. She also gave him a form that would allow him to get a state ID for a reduced fee of $7. Then back he went to the clinic waiting room so he could be seen by a doctor.

The clinic was packed with local residents who killed time by watching soap operas on the TV hanging from the ceiling. Sitting among them, Copeland seemed anxious. He fixated on getting new clothes and was nervous about finding a place to stay. His mother was a homeless drug addict and wouldn't be any help. His father moved to Jamaica when he was a kid. And his grandmother and brother long ago stopped taking him in whenever he was released because the outcome always seemed to be the same.

Still, Copeland was optimistic. He had big plans for getting his own apartment, a place where he could cook. He wanted to make reggae music and go back to school for video production. He says he quit taking hard drugs after a 1992 incident in which his heart failed after shooting heroin. So he reasoned that if he could just resist the lure of easy money from selling drugs and if he could stay within the fifty-mile travel limit imposed on him by his parole, he was sure he could emerge from his three-year term without further incident.

He also pledged to take better care of his health. "Back in the early Nineties, I didn't take my health seriously," he said. "I've had seven to eight hospitalizations. Highland and SF General, that's where I've been going to every time I get sick. I need to stay focused and stay positive and stay on my meds. If I have my inhalers, I don't have to go to the ER to be put on ventilators. I'm happy to get my medical situation out of the way because I've never dealt with it. I had an excuse — there was no way because there was no money for the bus."

After waiting nearly two hours, Copeland was called in to see Dr. Watson. Through a novel arrangement with the Discharge Planning Clinic at San Quentin, Copeland's medical records had been faxed to the doctor, who thumbed through them as he spoke.

"We want to provide a medical home for you, so to speak, so you don't have to go see someone new every time," Dr. Watson told Copeland. "Because what you are dealing with is pretty serious and I want to get it under control." The doctor suggested that Copeland meet with another Healthy Oakland staffer so he could get help filling out forms for housing, disability payments, psychological counseling, and emergency food stamps.

After another hour of paperwork, Williams reappeared to drive Copeland to get blood work done at a sister clinic. After that, it was off to the parole office, where Copeland was fitted with the GPS ankle bracelet required because one of his prior convictions was for "sexual penetration with foreign object by force." Then Williams took Copeland to a check-cashing store, so that the parolee would have about $130 in cash in his pocket. Their final destination was a motel within the roar of the Interstate 880.

"I'm glad I'm getting all of this done," Copeland said. "To be honest, I never done this much work to get it all together."

As Williams turned to go, there was a silence, as the realization dawned that, after today, the rest was up to Copeland. "People would kill to be in your place," Williams reminded him. "Stay encouraged. Everybody will tell you what to do, but I'll tell you a secret: You already know what to do. If you go down the other track, you know what is going to happen. If you stay on the track you're on, it'll be lovely. Stay on that track."

Policy makers and advocates say that connecting parolees such as Copeland to health care services is simply pragmatic public policy. Medical studies show that parolees tend to have higher rates of infectious disease and are at greater risk for heart problems than members of the general public. And within the first two weeks of their release from prison, parolees are thirteen times more likely to die — mostly due to drug overdoses and heart disease.

California inmates — more than 90 percent of whom are eventually released — carry a "high burden" of chronic and infectious disease, two-thirds are substance dependant, and more than half report having a mental illness, according to a 2009 study by the RAND Corporation. Various studies, including a survey of Alameda parolees by the nonprofit Urban Strategies Council and a group of formerly incarcerated individuals called All of Us or None, indicate that the majority of ex-offenders do not have health insurance, and often seek medical care via costly emergency room visits.

Meanwhile, as prison populations have grown, so have the number of parolees, resulting in more ex-offenders seeking medical care. The situation is particularly acute in California, which has reconfigured sentences for non-violent crimes and adopted policies for early release as a way to address prison overcrowding and the state's budgetary shortfall. According to the RAND report, the number of people released from California prisons has "increased nearly threefold" in the past 20 years.

The RAND study found that while parolees in California have a variety of health and social needs that should be addressed, they often can't get the services they need because they're going back to low-income communities where health services are severely strained. For instance, ex-offenders don't tend to manage their infectious diseases well. One recent study tracked 512 HIV-positive repeat offenders from the San Francisco County Jail over nine years and found that only 15 percent avoided interrupting their treatment regime.

The formerly incarcerated also tend to have higher rates of addiction and mental-health problems than the general public, situations that often manifest themselves in criminality. According to the Department of Justice, 33 percent of state inmates and 22 percent of federal inmates reported that they committed their current offense while under the influence of drugs. And in California, drug offenses accounted for 25.8 percent of the nearly 130,000 felony arrests in 2008. As of February 2010, there were 36,471 mentally ill inmates in California's prisons.

Addiction and criminal activity were definitely related in the case of Donald Williams. His first encounter with the prison system came in 1984, after he was caught selling marijuana. From that point on, whenever Williams was released from jail or prison, he'd go right back to drinking, fighting, and snorting cocaine. Alcoholism and substance abuse were the reasons he landed back in prisons and jails again and again.

"I didn't sleep; I passed out," he said of the 1980s. "When I got out of jail, first thing I'd do is buy a cold beer and by the time I got to Oakland, I was tipsy. And that opened the door to everything else. ... I used to be at the store at 6 a.m. drinking. But I had to stay away from that environment."

The turning point came during one of his last stints at Folsom State Prison, when a guard called him "riffraff" while he waited to enter the prison church. "I get in my cell and I looked in the dictionary for 'riffraff' and it said it meant 'rubbish' and 'scum of the earth.' I said, I'm not going to submit myself to this. It was real degrading. I got to get out of this."

When Williams was released from prison in the summer of 2008, he went directly to Healthy Oakland to sign up for health insurance and to volunteer at the organization, where half of the fifty-person staff consists of ex-offenders. He had suffered from stomach pain for years — later diagnosed as diverticulitis — and he saw Dr. Watson and started helping out around the clinic the very next day.

He also left the house where his sister was dealing with her own addiction problems, and moved for a period into the Healthy Oakland offices, sleeping on an air mattress in what is now the intake office.

"You can't reenter into the same thing you went to jail for," he noted. "The results will be the same or worse. You'll either end up in the hospital or in jail."

After five months as a volunteer, Williams was hired as the clinic's transportation chief. That's when he started wearing a black jacket with the words "No More Excuses" stitched across his heart, a motto that reflects the clinic's mission to provide services so that there would be no justifications for "going back to an unhealthy environment," Williams said.

In addition to Williams' San Quentin pickups, he also delivers patients from shelters and church housing to doctors appointments at the clinic. And every Wednesday he makes an appearance at the Alameda County Police & Correctional Team (PACT) meeting for recently released parolees at the Oakland parole office, where he preaches the gospel of Healthy Oakland. He is an evangelist today because the clinic, which is run by his half-brother Pastor Lankford, helped redeem him.

But Williams, who is deeply religious, said it was ultimately his faith that helped him lead a different life. "I had to get to the root cause — the alcohol — and then I just prayed," he said. "God blessed me and I stand here by the grace of God."

Last August, Williams was discharged from parole, which even he sometimes regards as a miracle.

"I'd been doing time since 1984 so I know at least three people at every PACT meeting," he said. "One guy saw me up there and he said, 'There sure is a God if you're doing it.'"

No one is arguing that health care will singlehandedly reduce crime, but some believe it could be a strong step forward that will also save taxpayers money in the process.

Williams said he believes health care — which inmates tend to positively associate with getting out of their prison cells — is the "grabber" that can get parolees started on a better path, a dynamic he sees at the weekly PACT meetings for parolees.

"The way I get them is by telling them about the free insurance," he said of his presentation. "They rush up afterward to say they need the help. Then they come here to see the doctor and to get their meds, and they'll see the movement around here. We can show them the computer lab and help them work on their résumé or do job searches, and we can tell them about all that while they wait for the doctor."

Rodney Brooks, chief of staff to County Supervisor Keith Carson and a member of the Alameda County Reentry Network Coordinating Council, says these efforts also make straightforward financial sense.

"If you have a seamless flow of information from when someone is inside a state or county facility and you can connect them with a clinic, it means they're not coming to the emergency room, which is important in these difficult budgetary times," he said. "If we can get our arms around treating the population so they're not coming into the ER, it saves the county millions of dollars. It's that simple."

But whether access to health care contributes to a reduction in recidivism is an open question. A study of a Rhode Island program called Project Bridgefound that female patients who received medical care along with intense case management had half the recidivism rate of two control groups. Research on female offenders released from New York City jails found that women with Medicaid were significantly less likely to be re-arrested than those without health insurance, although the authors noted that their study doesn't prove causation.

San Quentin's Discharge Planning Clinic, which coordinates prison handoff with Healthy Oakland and other clinics across the state, has an inmate return rate of 40 percent, which is lower than the state's 70 percent recidivism rate.

But it may also depend on the kind of care that the ex-offender needs and receives. A UCLA study found that mentally ill California parolees who visited outpatient clinics had a 37 percent lower recidivism rate than mentally ill parolees who didn't. A 2009 report by the California Department of Corrections and Rehabilitation concluded that offenders who completed both in-prison and community-based substance abuse treatment programs had a recidivism rate of 21.9 percent one year after release, compared with 39.9 percent for all parolees.

Every few weeks, Donald Williams gets up before dawn to make a similar errand of grace to pick up a chronically ill inmate on the day he is released from San Quentin. In April, he picked up a man who has cancer, and then drove him to see his parole agent, and then to Highland Hospital for a chemo appointment.

The parolee still checks in with Williams twice a week, and the Healthy Oakland staffer was recently trying to connect the ex-offender with a place to stay with his uncle, a deacon at a local church. "You can tell when people are ready," Williams said. "When he got in the car, he said, 'I'm fittin' to get off parole. He wanted to talk about getting off parole, and other people talk about where are the women, the cigarettes, and the alcohol. When I heard that, I said, 'Oh yeah, he's ready.'"

But Williams hasn't heard from Charles Copeland lately. It wasn't a stretch to assume that Copeland had violated his parole. A June 15 call to the Department of Corrections confirmed that Copeland is now incarcerated at a prison in Chino, California. While the corrections agency didn't provide details about Copeland's re-imprisonment, Williams deduced that at the very least, Copeland violated the terms of his parole by fleeing to Southern California.

Williams was disappointed. "I'm dumbfounded," he said. "He'd been out eighty days and he got frustrated and tried to see if he could make something happen. But you need to call someone when you're about to go off the deep end, and not someone who will just talk but who will say, 'Stay where you are; I'm coming.' He can call me. That's my message to him."

For Copeland, health care didn't bring the divine intervention that it did for Williams. But advocates like Bill Heiser of the Urban Strategies Council believes such reentry programs are still worth doing. "You cannot look at a one-time return to prison or jail as a failure," Heiser said. "We have to look a little more long-term. And what we are trying to do is build a system that supports people who are moving in and out of institutions. We've gotten into this state we're in with the growth in incarceration over the past twenty-plus years, and a few doctors appointments aren't going to change that. But this is a step we need to take in order to change that."

Bernice Yeung wrote this story while participating in The California Endowment Health Journalism Fellowships at USC's Annenberg School for Communication & Journalism.